Nokea
The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform prior to assessing the patient's uterus?
- A. Place the patient on the left side.
- B. Assess the passage of lochia.
- C. Ask the patient to void.
- D. Administer a dose of oxytocin.
Correct Answer: C
Rationale: The correct answer is C: Ask the patient to void. This is important prior to assessing the patient's uterus because a full bladder can displace the uterus and make it difficult to accurately assess its position and firmness. By asking the patient to void, the nurse ensures a more accurate assessment of the uterus. Placing the patient on the left side (A) is a position used to maximize uterine perfusion but is not necessary prior to assessing the uterus. Assessing the passage of lochia (B) is important but can be done after assessing the uterus. Administering oxytocin (D) may be indicated to help prevent postpartum hemorrhage but is not necessary prior to assessing the uterus.
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Which statement should alert the nurse to the possibility of ineffective bonding between mother and newborn?
- A. "My baby has my eyes."
- B. "No one in my family has that big of a nose."
- C. "Where did he get those long fingers?"
- D. "Is it normal for him to sleep so much?"
Correct Answer: C
Rationale: The correct answer is C because the statement "Where did he get those long fingers?" indicates a lack of recognition or acceptance of the newborn's physical characteristics, which may suggest a disconnect or lack of bonding between the mother and the baby. This statement does not show the mother identifying any physical traits of herself in the baby, unlike choices A and B. Choice D is a common concern among new parents and does not necessarily indicate ineffective bonding. In summary, choice C is correct as it demonstrates a potential lack of bonding based on the mother's statement about the baby's physical features, while the other choices do not indicate the same level of concern.
Which statement should alert the nurse to the possibility of ineffective bonding between mother and newborn?
- A. "My baby has my eyes."
- B. "No one in my family has that big of a nose."
- C. "Where did he get those long fingers?"
- D. "Is it normal for him to sleep so much?"
Correct Answer: C
Rationale: The correct answer is C because the statement "Where did he get those long fingers?" indicates a lack of recognition or acceptance of the newborn's physical traits, which could suggest a disconnect between the mother and infant. This statement may signal that the mother is not bonding effectively with the baby. In contrast, choices A, B, and D all demonstrate a degree of recognition or concern for the baby's physical characteristics or behaviors, which are more indicative of normal bonding behaviors between a mother and newborn.
A new mother expresses frustration about how to know what her baby wants. The mother states, 'I don't know what I expect, but then, the baby doesn't know either.' Which situation does the nurse use as an example of neonate communication?
- A. The baby is content to lie still on the mother's abdomen.
- B. The baby is easily awakened if irritated by loud noises.
- C. The baby resists eye contact if bored or disinterested.
- D. The baby roots for the breast when the cheek is stroked.
Correct Answer: D
Rationale: The correct answer is D because rooting reflex is a typical neonatal behavior where babies turn their head and open their mouth to search for a nipple when their cheek is touched. This reflex indicates the baby's communication of hunger and readiness to feed. This behavior is innate and essential for the baby's survival. In contrast, choices A, B, and C do not specifically demonstrate neonatal communication. Choice A does not involve any active communication or response from the baby. Choice B relates to a sensitivity to external stimuli rather than intentional communication. Choice C describes behavior that may not necessarily indicate communication but rather a lack of interest or engagement.
The physician has ordered the rubella vaccine to be given to a postpartum woman who is being discharged. Which should be included when providing education about the vaccine to the woman?
- A. Breastfeeding is contraindicated.
- B. The woman should avoid becoming pregnant after receiving the vaccine.
- C. The vaccine can safely be given to women with egg allergies.
- D. The woman must be separated from her infant for 24 hours after receiving the vaccine.
Correct Answer: B
Rationale: The correct answer is B: The woman should avoid becoming pregnant after receiving the vaccine. This is because the rubella vaccine contains a live virus that could potentially harm a developing fetus if the woman were to become pregnant shortly after receiving the vaccine. It is recommended to wait at least 1 month after vaccination before trying to conceive.
Choice A is incorrect because breastfeeding is not contraindicated after receiving the rubella vaccine. Choice C is incorrect as women with severe egg allergies should not receive the rubella vaccine due to potential allergic reactions. Choice D is incorrect as there is no need for the woman to be separated from her infant after receiving the rubella vaccine.
The physician has ordered the rubella vaccine to be given to a postpartum woman who is being discharged. Which should be included when providing education about the vaccine to the woman?
- A. Breastfeeding is contraindicated.
- B. The woman should avoid becoming pregnant after receiving the vaccine.
- C. The vaccine can safely be given to women with egg allergies.
- D. The woman must be separated from her infant for 24 hours after receiving the vaccine.
Correct Answer: B
Rationale: The correct answer is B because rubella vaccine is a live attenuated vaccine, which means it should not be given to pregnant women as it can potentially harm the fetus. Therefore, it is important for the postpartum woman to avoid becoming pregnant after receiving the vaccine to prevent any risks to future pregnancies.
Choice A is incorrect as breastfeeding is not contraindicated with the rubella vaccine. Choice C is incorrect because the rubella vaccine should not be given to individuals with severe egg allergies. Choice D is incorrect as there is no need for the woman to be separated from her infant after receiving the rubella vaccine.